General Summary

• Under supervision of a Registered Nurse, provides individualized patient care consistent with the mission and values of the University of Maryland Rehabilitation and Orthopaedic Institute (UMROI) and in accordance within the scope of practice, professional, and regulatory standards. Accountable to the supervising RN, patients and families for processes and outcomes during an episode of care. Serves as a fully engaged member of the interdisciplinary patient care services team. Participates in cost effective strategies that optimize patient outcomes.
• Must demonstrate the knowledge and skills necessary to provide care appropriate to the age, culture, ethnicity, and specific individual diagnostic needs of the patients served in his/her department. He/she must be able to assess and interpret data about the patient's status in order to identify each patient's specific needs and provide the care needed by the patient group (pediatric, adolescents and/or geriatric patient group, culture and diagnostic specific).
• Consistently expresses and demonstrates compassion and courtesy for patients. Extends courtesy and support to patient's families/visitors.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

Electronic/Paper documentation

Accurately and concisely records patient care along the continuum. Attends required training on electronic documentation. Demonstrates ability to document/enter data correctly in the medical record/EMR verified by chart review.

Wound Care

Performs patient care that promotes healing and maintains structural integrity of the skin. Performs comprehensive skin care including dressing changes for the patient requiring wound care. Identifies risk factors for impaired skin integrity and/or wound impairment. Collaborates with the Registered Nurse to implement appropriate strategies and/or treatment measures to prevent skin deterioration. Identifies criteria for nutrition and wound care consultative services.

Pain Management

Intervenes, alleviates or reduces pain to a level of comfort acceptable to the patient. Screens the patient for pain on initial admission/visit and during on-going care activities as evidenced by chart audit. Collaborates with the Registered Nurse to implement appropriate interventions to manage pain. Review of documentation. Completes annual competency for pain recognition and pain therapies- skill checklist on file.

Blood Glucose Monitoring (Accu-check)

Able to accurately perform testing and manage the care of the patient based on results achieved and clinical findings. Attends annual training for review and updates on blood glucose testing and monitoring equipment. Demonstrates proper technique and skills needed for obtaining accurate blood glucose results and documenting findings. Completes annual didactic and/or written testing with results kept on file. Quality monitoring performance is assessed annually and/or as needed at intervals based on performance criteria.

Collection of Specimens

Accurately follows procedural guidelines and uses proper technique(s) to obtain bodily specimen collection for laboratory testing. Completes annual didactic and/or written testing with results kept on file. Incorporates proper techniques for patient identification, method for collection of appropriate specimen(s), and documentationIV therapy - Accurately and successfully while using proper technique is able to perform venipuncture and peripheral intravenous catheter insertion. Demonstrates proper procedural guidelines and follows UMROI policy for IV therapy and Blood drawing. Documents procedure, relevant information, and outcomes in the medical record. Reports and/or uses appropriate intervention for any untoward events that occur during patient care. Manages the care of the insertion site using proper procedural guidelines according to UMROI policy.

• Medical Emergency Preparedness: Current CPR
• Medication Administration
• Fall Risk Assessment/Fall Risk Strategies
• Restraint application, monitoring and documentation
• Infection Control: Standard Precautions, Isolation Precautions
• Braden Scale/Skin Care
• IV Catheterization and Care
• Bladder management
• Respiratory Care: suctioning and trach care, etc.
• Oxygen Therapy
• Orthopedic/Rehab Device Care; e.g. braces, splints, CPM.
• Bowel management
• Rounding Initiative.

Respect for individuals, Customer Service, Teamwork and Collaboration:

• Models excellence in customer service behaviors. Identifies and acts on opportunities to respond to customer requirements. Takes action to prevent potential customer complaints.
• Initiates service recovery processes and completes appropriate documentation in response to customer concerns.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age, culture, ethnicity, spirituality, and individual diagnostic needs of the persons served.
• Uses hand-off communication to convey appropriate patient/clinical information.
• Identifies and addresses potential breeches in patient information management and confidentiality (HIPAA) issues.
• Serves as a collaborative resource and patient advocate within the interdisciplinary team.
• Mentors and provides an inclusive environment for peers, orientees, and students.
• Provides performance feedback as requested within peer review systems.
• Voices difference in opinion professionally through appropriate channels.

Leadership, Clinical and/or Technical Skills:

• Exhibits comprehensive, constructive thinking and clinical competency related to the patient population in the area of assignment.
• Contributes to the nursing process by collecting and reporting data on patient's health status that is systematic, individualized and accurate.
• Assists in the formulation of the plan of care by reporting and documenting observations of patients' condition and response to treatment.
• Collaborates with the RN and members of the health care team to develop, implement, and evaluate the plan of care including the patient's response to treatment.
• Demonstrates effective documentation practices including fields requiring co-signature.
• Supports change efforts, unit/organizational goals, and problem solving initiatives as a fully engaged member of the team.
• Monitors competency and performance of unlicensed staff.
• Participates in the coordinated approach to patient/family education in accordance with patient needs and barriers encountered.
• Other duties, as assigned.

Quality and Patient Safety:

• Ensures the safety of the clinical environment for patients, visitors, and other staff members.
• Demonstrates knowledge, practice, and accountability for compliance with the TJC National Patient Safety Goals.
• Detects, reports, and takes action to avoid or correct safety risks.
• Reports adverse events and near misses to appropriate management authority.
• Participates in the implementation of fall prevention strategies.
• Incorporates safe lifting techniques and body mechanics in daily practice.

Cost Effectiveness:

• Supports opportunities that improve patient flow and prevent care delays.
• Employs practices that improve efficiency, reduce costs, and maximize charge capture when delivering patient care.
• Effectively sets priorities and demonstrates time management skills.
• Inputs efficient and balanced self-scheduling data in compliance with staffing targets and guidelines.
• Maintains an awareness of financial implications of practice and recommends methods to reduce cost of care.

Education and Research:

• Assumes responsibility for maintaining competency and clinical knowledge base related to role.
• Identifies and addresses learning needs of self.
• Attends required in-services. Completes written and/or computerized training.
• Supports or participates in approved research projects.